Persistence of Psychological Distress in Surgical Patients

with Interest in Psychotherapy: Results of a 6-Month

Follow-Up
Leonie F. Kerper1., Claudia D. Spies1., Maria Loner1, Anna-Lena Salz1, Sascha Tafelski1, Felix Balzer1,
Edith Wei-Gerlach1, Tim Neumann1, Alexandra Lau1, Heide Glaesmer2, Elmar Brahler2, Henning Krampe1*
1 Department of Anesthesiology and Intensive Care Medicine, Campus Charite Mitte and Campus Virchow-Klinikum, Charite University Medicine Berlin, Berlin, Germany,
2 Department of Medical Psychology and Medical Sociology, University of Leipzig, Leipzig, Germany

Abstract
Objectives: This prospective observational study investigated whether self-reported psychological distress and alcohol use
problems of surgical patients change between preoperative baseline assessment and postoperative 6-month follow-up
examination. Patients with preoperative interest in psychotherapy were compared with patients without interest in
psychotherapy.
Methods: A total of 1,157 consecutive patients from various surgical fields completed a set of psychiatric questionnaires
preoperatively and at 6 months postoperatively, including Patient Health Questionnaire-4 (PHQ-4), Brief Symptom Inventory
(BSI), Center for Epidemiologic Studies Depression Scale (CES-D), World Health Organization 5-item Well-Being Index (WHO5), and Alcohol Use Disorder Identification Test (AUDIT). Additionally, patients were asked for their interest in
psychotherapy. Repeated measure ANCOVA was used for primary data analysis.
Results: 16.7% of the patients were interested in psychotherapy. Compared to uninterested patients, they showed
consistently higher distress at both baseline and month 6 regarding all of the assessed psychological measures (ps between
,0.001 and 0.003). At 6-month follow-up, neither substantial changes over time nor large time x group interactions were
found. Results of ANCOVAs controlling for demographic variables were confirmed by analyses of frequencies of clinically
significant distress.
Conclusion: In surgical patients with interest in psychotherapy, there is a remarkable persistence of elevated self-reported
general psychological distress, depression, anxiety, and alcohol use disorder symptoms over 6 months. This suggests high
and chronic psychiatric comorbidity and a clear need for psychotherapeutic and psychiatric treatment rather than transient
worries posed by facing surgery.
Citation: Kerper LF, Spies CD, Loner M, Salz A-L, Tafelski S, et al. (2012) Persistence of Psychological Distress in Surgical Patients with Interest in Psychotherapy:
Results of a 6-Month Follow-Up. PLoS ONE 7(12): e51167. doi:10.1371/journal.pone.0051167
Editor: Jerson Laks, Federal University of Rio de Janeiro, Brazil
Received July 17, 2012; Accepted October 29, 2012; Published December 5, 2012
Copyright: 2012 Kerper et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was supported by the DFG (German Research Foundation, Grant KR 3836/3-1). The funders had no role in study design, data collection and
analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: henning.krampe@charite.de
. These authors contributed equally to this work.
Current address: Department of Anesthesiology and Intensive Care Medicine, Campus Charite Mitte and Campus Virchow-Klinikum, Charite-University Medicine
Berlin Chariteplatz 1, 10117 Berlin, Germany

worries posed by facing surgery. OHara et al (1989) found in a

large sample study that the rate of patients with clinically
significant psychological distress was even higher 3 months after
surgery than at the day before surgery [1]. Recent investigations of
smaller samples and with follow-up times ranging from 3 days to 3
to 5 years show a differentiated picture: Some studies confirmed
the increase of psychological distress [10,11], others found no
significant change [1214], a significant decrease [1518], patterns
of no significant change and decrease [19,20], or patterns of both
increase and decrease [21,22]. In a recent study, we examined
N = 4,568 surgical patients in the preoperative anesthesiological
assessment clinic and found a rate of clinically significant

Introduction
Few studies have investigated psychological distress in surgical
patients. With the exception of two earlier large-scale investigations [1,2] research is mostly based on small samples, distinct
surgical fields and specific psychological factors. Taken together,
there is some evidence that psychological distress is high in surgical
patients during the pre- and perioperative period regarding
depression, e.g. [37], anxiety, e.g. [1], and alcohol use disorders,
e.g. [8,9]. However, it is not clear to which extent elevated selfreported symptoms of preoperative psychological distress reflect
either clinically significant psychiatric symptoms or transient

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Psychological Distress in Surgical Patients

another clinical trial; homelessness; admitted in police custody;

unwilling to use or incapable of using a computer. Upon receipt of
written informed consent, eligible patients completed the computer-assisted self-assessment which took approximately 25 minutes
per patient. During the pilot phase (April to December 2009),
1,500 patients were enrolled, and during the implementation
phase (January to June 2010) 3,068 patients. Detailed information
on the inclusion process is available for the implementation phase:
A total of 7,178 patients were assessed for eligibility, with 4,110 not
being eligible according to the inclusion/exclusion criteria and 953
refusing to participate (details in [23]). Because the primary
objective of the feasibility study was to include as many patients as
possible in the baseline assessment, inclusion and exclusion criteria
were set rather general. As a consequence, it was no exclusion
criterion when patients did not want to participate in the 6-month
follow-up and they were only asked to indicate whether they would
agree to be contacted by the researchers after 6 months. In total,
4,568 patients participated in both pilot phase and implementation
phase of BRIA. 1,838 patients did not show any interest in the 6month follow-up. Of the remaining 2,730 patients, 1,533 did not
send back the follow-up questionnaire and 12 were not reachable
because the address was unknown. Of 26 patients information was
received that they had died during hospital stay or follow-up
period, and 2 patients sent back the questionnaire but did not fill
in, resulting in 1,157 patients who participated in both baseline
and 6-month follow-up.

preoperative psychological distress of up to 38% [23]. Independently of surgical field or physical health, interest in psychotherapy
was significantly associated with the intensity of self-reported
symptoms of general psychological distress, depression, anxiety
and substance use disorders. However, only a prospective
longitudinal investigation will provide data to clarify whether
elevated symptoms remain stable over time or decrease after
patients have overcome the hospital stay.
This study investigated whether self-reported psychological
distress and alcohol use problems of surgical patients change
between preoperative baseline assessment and postoperative 6month follow-up examination. Patients with preoperative interest
in psychotherapy were compared with patients without interest in
psychotherapy. In order to control for types of questionnaire, a set
of 12 standardized psychological scales and subscales, respectively,
was applied.

Materials and Methods

Design and Setting
This prospective observational study was carried out from April
2009 to December 2010 as part of a feasibility study investigating
Bridging Intervention in Anesthesiology (BRIA; approved by the
local Ethics Committee [EA1/23/2004, Amendment April 2009]),
which is currently followed by a randomized controlled trial.
Baseline assessment of the feasibility study was performed in the
preoperative assessment clinics of the Charite University
Medicine Berlin, and postoperative 6-month follow-up was carried
out as a postal questionnaire investigation.
BRIA has been designed as a psychotherapeutic stepped care
approach to reach patients from different surgical fields. The
program consists of two major therapeutic elements: 1) A
computer assisted self-assessment of social, lifestyle and psychological factors including a comprehensive battery of psychiatric
screening instruments, items concerning interest in psychotherapy,
as well as computerized tailored brief written advice, and; 2)
Psychotherapeutic contacts with the objective either to motivate
patients with psychiatric disorders and support them in participating in subsequent outpatient psycho- and addiction therapy, or
to improve the patients psychological symptoms and well-being so
that a subsequent psychosocial treatment is not necessary. As
previously reported [23], the primary objective of BRIA is to
bridge the gap between inpatient surgical treatment and outpatient
psychosocial health care including psychotherapy, psychiatry, and
addiction treatment.
During the pilot phase of BRIA (April to December 2009), the
treatment program was introduced in the preoperative assessment
clinics and the computer-assisted self-assessment took place
approximately two to three days per week between 9.00 am and
5.00 pm. In the following implementation phase (January to June
2010) BRIA was integrated in the routine care of the hospital so
that the computer assisted self-assessment was performed from
Monday to Friday between 9.00 am and 5.00 pm in order to
cover the complete opening hours of the assessment clinics.
Surgical patients examined by an anesthesiologist in the preoperative assessment clinics were assessed for inclusion and exclusion
criteria and, in case of eligibility, asked for participation in the
study. Inclusion and exclusion criteria were defined as follows.
Inclusion criteria: Patient in preoperative anesthesiological assessment clinic, sufficient knowledge of German language, age $18
years, written informed consent. Exclusion criteria: Surgery with
an emergency or urgent indication; inability to attend the
preoperative assessment clinic (bedside visit); members of the
hospital staff; relatives of the study team; study participation in
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Measurements
A set of standardized screening questionnaires with sound
psychometric properties covered the domains of general psychiatric distress, depression, well-being, generalized anxiety and
alcohol use disorders: Patient Health Questionnaire-4 (PHQ-4
[24,25]), Brief Symptom Inventory (BSI [26]), Center for
Epidemiologic Studies Depression Scale (CES-D [27]), World
Health Organization 5-item Well-Being Index (WHO-5 [28]), and
Alcohol Use Disorder Identification Test (AUDIT [29,30]). Details
of the questionnaires are described in Table 1. Additional singleitem questions dealt amongst others with demographic information, subjective health status (visual analogue scale of the EuroQol
5 Dimensions, EQ-5D [31]), as well as interest in psycho- and/or
addiction therapy sessions of BRIA (Would you like to have
psychotherapy sessions/addiction counselling during your hospital
stay?).
The evaluation of patients perioperative risk according to the
ASA (American Society of Anesthesiologists) physical status
classification system was used as an overall indicator for physical
health [32,33]. The evaluation was performed by the anesthesiologists who did the preoperative assessment. The ASA system
classifies patients in one of four categories: (1) Healthy patient; (2)
mild systemic disease, no functional limitation; (3) severe systemic
disease with definite functional limitation; (4) severe systemic
disease that is a constant threat to life. The fifths category which
comprises moribund patients was not used in this study.
Information on the surgical field was obtained from the electronic
patient management system of the Charite University Medicine
Berlin and comprised the categories 1) abdomino-thoracic surgery,
2) peripheral surgery, 3) neuro, head and neck surgery. Data on
ASA classification and surgical field were available for 715 patients
in the implementation phase.

Sample
Univariate analyses showed that the 1,157 participants differed
from the 3,411 patients who did not participate in the follow-up
with regard to interest in psychotherapy, demographic character2

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Psychological Distress in Surgical Patients

Table 1. Standardized self-report questionnaires that were assessed at baseline (T1) and 6-month follow-up (T2).

Name

Description

Patient Health Questionnaire-4: PHQ-4 [24]

Ultra-brief screening tool: Subscales for depression (PHQ-2), anxiety (GAD-2), 1 single-item for impairment
rating.
Domains: Depression, anxiety; time frame: Past 14 days.
5 items, 4-point Likert scale from 0 to 3; for PHQ-2 and GAD-2 each 2 items, ranges from 0 to 6.
Cut off score: PHQ-2 sum score: $3; GAD-2 sum score: $3 [24,25].
Center for Epidemiologic Studies Depression Scale:
CES-D [27]
Short version of the CES-D: Frequency of depressive symptoms.
Domain: Depression; time frame: Past 7 days.
15 items, 4-point Likert scale from 0 to 3; total sum score from 0 to 45.
Cut off score: CES-D sum score: $18 [27].
Brief Symptom Inventory: BSI [26]
Short version of the Symptom Checklist 90-R (SCL-90-R): Severity of psychiatric symptoms.
Domains: General and specific psychological distress; time frame: Past 7 days.
53 items, 5-point Likert scale from 0 to 4; total mean score from 0 to 4. Applied scores in this study: Global
severity index (GSI), subscales depression, anxiety, interpersonal sensitivity, phobic anxiety.
Cut off score for GSI, depression, anxiety, interpersonal sensitivity, phobic anxiety: T scores: $0.63 [26].
World Health Organization 5-item Well-Being Index:
WHO-5 [28]
Short depression screening tool of the WHO.
Domain: Psychological well-being (mood, interests, energy, sleep, psychomotor functioning); time frame: Past
14 days.
5 items, 6-point Likert scale from 0 to 5; total sum score from 0 to 25; higher scores indicating better wellbeing.
Cut off score: WHO-5 sum score ,14, clinically relevant depressive state [28].
Alcohol Use Disorder Identification Test:
AUDIT [29,30]
WHO screening tool for alcohol-related problems.
Domain: Hazardous and harmful alcohol consumption, and alcohol-related problems; time frame: Past 12
months.
10 items, 5-point Likert scale from 0 to 4; total sum score from 0 to 40. Applied scores in this study: AUDIT sum
score for any alcohol use disorder, AUDIT-C score for risky alcohol consumption (sum of items 1 to 3).
Cut off score: AUDIT sum score: $8 for men, $5 for women [29]; AUDIT-C score: .4 for men, .3 for women
[30].
doi:10.1371/journal.pone.0051167.t001

and nonparticipants of the follow-up were first compared with

univariate analyses by T test and Chi-squared test; in a second
step, multivariate analyses were performed by entering all
variables showing group differences with a p,.05 in univariate
analyses into a logistic regression model; odds ratios [OR] with
95%-confidence intervals were given. A two-tailed p-value ,0.05
was considered statistically significant. Comparison of patients
with and without interest in psychotherapy were carried out with
Chi-squared test for categorical and T test for metric data.
Change of psychological distress between baseline assessment
(T1) and 6-month follow-up (T2) in patients with and without
interest in psychotherapy was tested with McNemars test for
categorical data and repeated measures ANCOVA for metric
data. Repeated measures ANCOVA included as dependent
variables the T1 and T2 measures of psychological distress, as
within-subject factor the time points T1 and T2, as betweensubject factors interest in psychotherapy, gender and partnership
status, as well as age as covariate. Analyses were carried out
twofold, on raw data of the questionnaires (ANCOVA), as well as

istics and diverse clinical factors (Table 2). A multivariate logistic

regression model with the dependent variable participant vs.
nonparticipant and all variables with a significant effect in
univariate analyses as covariates revealed that only four covariates
continued to indicate significant differences (in order to prevent
artificial effects, only the total AUDIT score but not the AUDIT-C
subscore was included): Age [OR 1.03 (95% CI 1.021.04),
p,0.001], gender [OR 1.43 (95% CI 1.181.74), p,0.001],
interest in psychotherapy [OR 1.65 (95% CI 1.232.20),
p = 0.001], and university entrance qualification [OR 1.26 (95%
CI 1.051.51), p = 0.015].

Statistical Analyses
Data were entered into a computerized database and statistical
analyses were performed with SPSS Statistics for Windows,
Version 19 (SPSS Inc., Chicago, Illinois 60606, USA). Results
were expressed as relative frequencies in percent, mean (M) and
standard deviation (SD), estimated marginal mean (EMM) and
standard error of the mean (SEM), respectively. Participants
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Psychological Distress in Surgical Patients

Table 2. Comparisons of participants (n = 1,157) and nonparticipants (n = 3,411) of the 6-month follow-up; n (%); mean [SD].
Participants n = 1,157+

Nonparticipants n = 3,411+

Interest in psychotherapy

193 (16.7)

336 (9.9)

,0.001

Age: Years

52.49 [15.53]

45.75 [16.02]

,0.001

Women

667 (57.6)

1708 (50.1)

,0.001

Partnership status: Living with a partner

768 (67.1)

2051 (60.8)

,0.001

Level of education: University entrance qualification

511 (44.6)

1374 (40.5)

0.015

ASA I

172 (24.1)

773 (34.1)

ASA II

416 (58.2)

1218 (53.8)

ASA III

125 (17.5)

270 (11.9)

ASA IV

2 (0.3)

5 (0.2)

283 (39.6)

868 (38.3)

ASA Classification++a)

,0.001

Surgical field++
Abdomino thoracic surgery

0.028

Peripheral surgery

235 (32.9)

660 (29.1)

Neuro-, head and neck surgery

197 (27.6)

738 (32.6)

BSI GSI, severity of psychological distressb)

0.34 [0.37]

0.33 [0.39]

0.168

Self-rating of current subjective healthc)

64.31 [24.78]

64.22 [27.49]

0.917

WHO-5d)

14.54 [5.83]

14.44 [5.79]

0.587

PHQ-2

e)

1.48 [1.44]

1.40 [1.40]

0.094

CES-Df)

9.98 [6.90]

9.56 [6.56]

0.078

BSI depressionb)

0.32 [0.53]

0.30 [0.52]

0.377

GAD-2g)

1.35 [1.51]

1.23 [1.41]

0.013

BSI anxietyb)

0.39 [0.47]

0.35 [0.47]

0.008

BSI interpersonal sensitivityb)

0.35 [0.53]

0.34 [0.53]

0.347

BSI phobic anxietyb)

0.18 [0.38]

0.17 [0.37]

0.544

AUDIT sum scoreh)

2.79 [3.15]

3.09 [3.52]

0.007

AUDIT-C: Risky alcohol consumptionh)

2.34 [1.96]

2.50 [2.13]

0.015

Number ranges for the specific variables from 1,123 to 1,157 (participants) and from 3,236 to 3,411 (nonparticipants) because of missing data.
Data for ASA and surgical field are available for the implementation phase; numbers account to 715 (participants), and 2266 (nonparticipants) because of missing
data.
a)
ASA (American Society of Anesthesiologists) physical status classification: (I) Healthy patient; (II) Mild systemic disease, no functional limitation; (III) Severe systemic
disease with definite functional limitation; (IV) Severe systemic disease that is a constant threat to life;
b)
BSI: Brief Symptom Inventory; GSI: General severity index;
c)
Visual analogue scale of the EQ-5D, 0 to 100 with higher scores indicating better subjective health;
d)
WHO-5: World Health Organization 5-item Well-Being Index;
e)
PHQ-2: Patient Health Questionnaire-4, depression subscale;
f)
CES-D: Center for Epidemiologic Studies Depression Scale;
g)
GAD-2: Patient Health Questionnaire-4, anxiety subscale;
h)
AUDIT: Alcohol Use Disorder Identification Test, AUDIT-C: AUDIT subscore for risky alcohol consumption.
doi:10.1371/journal.pone.0051167.t002
++

was considered statistically significant for each of the 11 single

McNemars tests.

regarding rates of cases with clinically significant psychological

distress (McNemars test). A case with clinically significant distress
was defined as a patient scoring above the cut off score of a given
questionnaire; cut off scores of all measures are shown in Table 1.
Bonferroni corrections were used in order to prevent the increase
of type I error in ANCOVAs and McNemars tests. Analyzing 12
measures of psychological distress as dependent variables (BSI
GSI, subjective health, WHO-5, PHQ-2, CES-D, BSI depression,
GAD-2, BSI anxiety, BSI interpersonal sensitivity, BSI phobic
anxiety, AUDIT sum score, AUDIT-C), a two-tailed p-value
,0.0041 (0.05/12) was considered statistically significant for each
of the 12 single tests of the ANCOVA model. Because there are no
cut off scores indicating clinically significant distress of the variable
subjective health, only 11 of the 12 measures of psychological
distress were analyzed as dependent variables of the McNemars
tests. As a consequence, a two-tailed p-value ,0.0045 (0.05/11)

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Results
Out of all 1,157 participants, 193 patients (16.7%) were
interested in psychotherapy, and 964 (83.3%) were not interested.
Patients with interest in psychotherapy were statistically significantly younger (p,0.001), were more likely to be female
(p = 0.012) and less likely to live with a partner (p,0.001).
However, there was no significant difference regarding surgical
field (p = 0.731) and ASA classification (p = 0.122) (Table 3).
In order to control for the differences in sociodemographic
characteristics, the ANCOVAs analyzing the course of selfreported psychological distress include gender and partnership
status as additional between-subject factors and age as a covariate;

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Psychological Distress in Surgical Patients

Table 3. Sociodemographic and clinical characteristics of all participants of the 6-month follow-up (N = 1,157), as well as
comparison of patients who showed interest in psychotherapy (n = 193) and patients who were not interested in psychotherapy
(n = 964); mean [SD], n (%).

All participants
N = 1,157+

Patients interested
in psychotherapy
n = 193+

Patients not
interested in
psychotherapy
n = 964+

Age: Years

52.49 [15.53]

48.95 [13.61]

53.19 [15.80]

,0.001

Male

490 (42.40)

66 (34.20)

424 (44.00)

0.012

Sociodemographic characteristics

Partnership status: Living with a partner

768 (67.10)

106 (56.10)

662 (69.20)

,0.001

Level of education: University entrance qualification

511 (44.60)

93 (48.40)

418 (43.90)

0.245

ASA I

172 (24.10)

18 (17.80)

154 (25.10)

ASA II

416 (58.20)

58 (57.40)

358 (58.30)

ASA III

125 (17.50)

25 (24.80)

100 (16.30)

ASA IV

2 (0.30)

0 (0.00)

2 (0.30)

Clinical characteristics
ASA Classification++a)

0.122

Surgical field++

0.731

Abdomino thoracic surgery

283 (39.60)

43 (42.60)

Peripheral surgery

235 (32.90)

30 (29.70)

240 (39.10)
205 (33.40)

Neuro-, head and neck surgery

197 (27.60)

28 (27.70)

169 (27.50)

+
Number ranges for the specific variables from 1,145 to 1,157 (all participants), from 189 to 193 (patients interested in psychotherapy) and from 953 to 964 (patients not
interested in psychotherapy) because of missing data.
++
Data for ASA and surgical field are available for the implementation phase; numbers account to 715 (all participants), 101 (patients interested in psychotherapy, and
614 (patients not interested in psychotherapy) because of missing data.
a)
ASA (American Society of Anesthesiologists) physical status classification: (I) Healthy patient; (II) Mild systemic disease, no functional limitation; (III) Severe systemic
disease with definite functional limitation; (IV) Severe systemic disease that is a constant threat to life.
doi:10.1371/journal.pone.0051167.t003

and 6-month follow-up in both patient groups. The most

important finding is that interested patients showed consistently
high distress at both baseline and month 6 regarding all of the
assessed psychological measures of general distress, depression,
anxiety, subjective health, and alcohol use disorder symptoms.
This remarkable persistence suggests high and chronic psychiatric
comorbidity and a clear need for psychotherapy rather than
transient worries posed by facing surgery. These results might be
considered as unsurprising in a setting of psychosocial health care.
However, data were collected in preoperative anesthesiological
assessment clinics where surgical patients are examined by an
anesthesiologist to clarify anesthesia related risks of the intended
surgery and to evaluate the patients individual level of risk. In this
setting, patients prepare to undergo surgery and both patients and
clinicians do not expect psychological screening programs.
Clinically significant preoperative psychological distress may be
misinterpreted by anesthesiologists and surgeons as transient
worries about somatic diagnoses and the forthcoming surgery.
Thus, it is important to provide evidence that patients with high
preoperative psychological distress and interest in psychotherapy
do not easily improve after having overcome surgery and the
hospital stay. From a psychotherapeutic perspective it makes sense
to treat chronic psychiatric comorbidity in surgical patients who
are motivated for therapy. But also from a medical perspective this
implication becomes comprehensive: Recent studies provided
evidence that untreated depression, anxiety and substance use
disorders are associated with perioperative complications and
increased morbidity and mortality, leading to worse surgical
outcomes and higher health care costs of surgical patients [39,34
38]. In order to properly assess and treat psychological distress in

results are shown in Table 4. Patients with interest in psychotherapy showed considerably higher distress than patients without
interest in psychotherapy at baseline and at month 6 regarding all
12 measures of distress, with ps between ,0.001 and 0.003 for the
different comparisons (Table 4). Importantly, neither of the two
groups showed statistically significant changes over time in 11
scales. Only in one scale a small but statistically significant change
occurred: Both groups had a slight increase in BSI interpersonal
sensitivity (p,0.001). Significant interaction effects were only
observed for GAD-2 (p = 0.002) and BSI anxiety (p = 0.002) with a
stronger decrease in both anxiety scales in patients with interest in
psychotherapy.
Similar results were found with regard to clinically relevant
psychological symptoms (details in Table 5). In patients with
interest in psychotherapy, rates of clinically significant symptoms
were high and stable between baseline and month 6 regarding all
tested measures. Patients without interest in psychotherapy
showed low rates of clinically significant distress that also remained
stable between baseline and month 6. Interestingly, rates even
increased statistically significantly in two scales, BSI GSI
(p = 0.001) and BSI depression (p = 0.001).

Discussion
To the authors knowledge, this is the first long-term study on
psychological distress in surgical patients that included interest in
psychotherapy as a group factor. The results revealed that (1)
patients with interest in psychotherapy differed considerably from
patients without interest in psychotherapy; (2) there were no
substantial changes of distress between preoperative assessment
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15.51 (0.50)

CES-De)

6
2.90 (0.15)

AUDIT-C: Risky alcohol consumptiong)

2.70 (0.15)

4.15 (0.25)

0.43 (0.04)

0.82 (0.04)

0.62 (0.03)

2.06 (0.11)

0.82 (0.05)

15.61 (0.63)

2.33 (0.11)

11.48 (0.45)

56.43 (1.85)

0.72 (0.03)

2.35 (0.07)

2.78 (0.11)

0.12 (0.01)

0.28 (0.02)

0.31 (0.02)

1.10 (0.05)

0.25 (0.02)

8.98 (0.23)

1.29 (0.05)

15.22 (0.20)

65.95 (0.91)

0.28 (0.01)

2.35 (0.07)

2.86 (0.12)

0.15 (0.02)

0.32 (0.02)

0.28 (0.02)

1.03 (0.05)

0.33 (0.02)

8.64 (0.30)

1.35 (0.05)

15.40 (0.21)

69.13 (0.86)

0.33 (0.02)

EMM (SEM)

0.003

,0.001

,0.001

,0.001

,0.001

,0.001

,0.001

,0.001

,0.001

,0.001

,0.001

,0.001

Group

0.675

0.217

0.037

,0.001

0.622

0.704

0.0043

0.776

0.111

0.603

0.250

0.005

Time

0.077

0.952

0.164

0.846

0.002

0.002

0.423

0.479

0.025

0.511

0.707

0.307

Group x Time

+
Repeated measures ANCOVA; estimated marginal means (EMM) and standard error of the mean (SEM); statistical significance of Bonferroni correction: p,0.0041; T1 (preoperative baseline assessment) and T2 (postoperative 6
months follow-up) as within-subject factors, therapy interest as between subject factor; covariate: age; additional between-subject factors: gender and partnership status.
++
Number ranges for the specific variables from 173 to 187 (patients interested in therapy contacts), and from 878 to 938 (patients not interested in therapy contacts) because of missing data
a)
BSI: Brief Symptom Inventory; GSI: General severity index
b)
Visual analogue scale of the EQ-5D, 0 to 100 with higher scores indicating better subjective health
c)
WHO-5: World Health Organization 5-item Well-Being Index
d)
PHQ-2: Patient Health Questionnaire-4, depression subscale
e)
CES-D: Center for Epidemiologic Studies Depression Scale
f)
GAD-2: Patient Health Questionnaire-4, anxiety subscale
g)
AUDIT: Alcohol Use Disorder Identification Test, AUDIT-C: AUDIT subscore for score for risky alcohol consumption
doi:10.1371/journal.pone.0051167.t004

4.08 (0.24)

AUDIT sum score: Alcohol abuse/dependenceg)

Alcohol problems

0.45 (0.03)

0.77 (0.04)

BSI interpersonal sensitivitya)

BSI phobic anxiety

0.77 (0.03)

BSI anxietya)

a)

2.51 (0.11)

GAD-2f)

Anxiety

0.79 (0.04)

2.55 (0.11)

PHQ-2d)

BSI depression

10.97 (0.43)

WHO-5c)

a)

54.18 (1.95)

Self-rating of current subjective healthb)

Depression

0.70 (0.03)

BSI GSI, severity of psychological distressa)

General psychological distress and subjective health

EMM (SEM)

EMM (SEM)

T2

T1

T2

T1

EMM (SEM)

Patients without interest in

therapy contacts n = 964++

Patients with interest in therapy

contacts n = 193++

Table 4. 6-month follow-up of psychological distress and alcohol use problems of surgical patients with interest in psychotherapy (n = 193) and surgical patients without interest
in psychotherapy (n = 964).+

Psychological Distress in Surgical Patients

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Psychological Distress in Surgical Patients

Table 5. 6-month follow-up of rates of clinically significant distress and alcohol use problems of surgical patients with interest in
psychotherapy (n = 193) and surgical patients without interest in psychotherapy (n = 964).+

Patients with interest in

therapy contacts n = 194++

Patients without interest in

therapy contacts n = 966++

T1

T2

Time

T1

T2

Time

n (%)

n (%)

n (%)

n (%)

88 (46.8)

83 (44.1)

.576

98 (10.5)

135 (14.4)

.001

WHO-5b)

123 (64.4)

111 (58.1)

.162

302 (32.1)

291 (30.9)

.505

PHQ-2c)

82 (43.4)

64 (33.9)

.041

131 (14.1)

141 (15.2)

.490

CES-Dd)

71 (38.4)

65 (35.1)

.497

86 (9.4)

116 (12.6)

.005

73 (38.2)

72 (37.7)

1.00

88 (9.4)

121 (12.9)

.001

General psychological distress

BSI GSI, severity of psychological distressa)
Depression

BSI depression

a)

Anxiety
GAD-2e)

71 (38.0)

52 (27.8)

.018

106 (11.6)

80 (8.8)

.018

71 (37.4)

49 (25.8)

.005

83 (8.8)

75 (8.0)

.475

BSI interpersonal sensitivitya)

53 (27.7)

56 (29.3)

.761

54 (5.8)

64 (6.8)

.268

BSI phobic anxietya)

58 (30.7)

47 (24.9)

.108

69 (7.3)

88 (9.3)

.040

AUDIT sum score: Alcohol abuse/dependencef)

35 (18.6)

35 (18.6)

1.00

83 (8.9)

86 (9.3)

.810

AUDIT-C: Risky alcohol consumptionf)

49 (26.3)

43 (23.1)

.362

164 (18.1)

148 (16.3)

.137

BSI anxiety

a)

Alcohol problems

+
McNemars test; T1: Preoperative baseline assessment; T2: Postoperative 6 months follow-up; n (%); statistical significance of Bonferroni correction: p,0.0045.
A case with clinically significant distress was defined as a patient scoring above the cut off score of a given questionnaire (see Table 1 for cut off scores of all measures).
++
Number ranges for the specific variables from 185 to 191 (patients interested in therapy contacts), and from 907 to 943 (patients not interested in therapy contacts)
because of missing data.
a)
BSI: Brief Symptom Inventory; GSI: General severity index;
b)
WHO-5: World Health Organization 5-item Well-Being Index;
c)
PHQ-2: Patient Health Questionnaire-4, depression subscale;
d)
CES-D: Center for Epidemiologic Studies Depression Scale;
e)
GAD-2: Patient Health Questionnaire-4, anxiety subscale;
f)
AUDIT: Alcohol Use Disorder Identification Test, AUDIT-C: AUDIT subscore for score for risky alcohol consumption.
doi:10.1371/journal.pone.0051167.t005

surgical patients, cost-efficient approaches are needed that are

based on interdisciplinary collaboration of clinicians from anesthesiology, surgery and psychology. A stepped care program may
fulfil both clinical and economical demands of such an approach
[23]: Screening for psychological distress, brief motivational
interventions, as well as early supportive interventions for
transiently elevated perioperative distress can be performed by
psychologically trained nursing staff. After the screening, those
patients who wish to be visited by a psychotherapist may
communicate their interest to the nursing staff to arrange a first
appointment. Non-confrontational brief advice should be offered
to patients who show clinically significant distress but lack
motivation for therapy. The data of the present study suggest
that patients with both clinically significant preoperative psychological distress and the explicit interest in psychotherapy are at an
increased risk to have persistently high distress after 6 months. As a
consequence, for these patients, the therapeutic steps after the
screening should comprise detailed psychological assessment,
clarification of psychiatric diagnoses according to ICD-10, first
psychotherapy sessions including motivational interviewing, and, if
required, the initiation of longer psychosocial treatment options.
The lack of any substantial changes of psychological distress
over time that was found in this study is in agreement with
previous studies in small samples of specific surgical patient groups
that found no significant change of clinically relevant depression
and anxiety during follow-up times between 1 month and 12
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months, e.g. [1214]. The slight decrease of anxiety in patients

with interest in psychotherapy can be considered as being
consistent with studies that reported a decrease of state anxiety
between 3 days and 3 months postoperatively without examining
clinically significant anxiety [16,20]. However, there is a clear
contradiction to investigations that observed a clear and significant
postoperative decrease of clinically significant depression and
anxiety during 6 months, e.g. [15,17,18]. In patients who were not
interested in psychotherapy, there seems to be an increase of some
clinically significant symptoms of general distress and depression
by month 6. This partial result is consistent with the findings of
OHara et al (1989) [1], as well as Gallagher & McKinley (2009)
[10] and Tsapakis et al (1989) [11] who found a significant
increase of psychiatric symptomatology in the postoperative period
with follow-up times between 8 and 12 weeks. Finally, the results
are partly inconsistent with the findings of Krannich et al (2007)
[19] who observed no significant changes regarding the rates of
clinically relevant depression and anxiety but a significant decrease
when analyzing raw data of the Hospital Anxiety and Depression
Scale (HADS) with T tests.

Methodological Limitations
This study is a substudy of the feasibility study of BRIA that did
not strictly focus on long-term investigation. As a consequence, a
large number of patients failed to participate in the follow-up so
that an effect of self-selection has to be assumed for this substudy.
7

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Psychological Distress in Surgical Patients

Univariate comparison of participants and nonparticipants of the

follow-up showed that participants were significantly older, were
more likely to be female, to live with a partner, to be with
university entrance qualification, and that they had worse
preoperative physical health. Additionally, they scored higher
regarding general anxiety but they reported less alcohol use
problems. Importantly, the percentage of patients with interest in
psychotherapy was higher in participants (16.7%) than in
nonparticipants (9.9%). On the other hand, there were no
significant differences regarding subjective health and most
domains of psychological distress, depression and anxiety.
Multivariate analyses identified only four important factors that
characterized study participants: Higher age, as well as higher
percentages of women and patients with interest in psychotherapy
and with university entrance qualification. About the reasons why
participants and nonparticipants differed regarding these characteristics can only be speculated. A self-selection of patients with
more severe psychiatric symptoms can be ruled out because both
groups did not differ substantially regarding preoperative psychological distress. On the other hand, it might be assumed that the
characteristics associated with participation are related to diverse
personality factors, like conscientiousness, interest in psychological
research, or the need to disclose ones status of subjective health,
patient satisfaction and quality of life. To conclude, generalization
is a major methodological limitation of this study. It is open
whether the results can be generalized to samples with participants
who are younger and who are more likely to be men, without
university entrance qualification and who are less likely to show
interest in psychotherapy.
Another issue that has to be mentioned is the use of self-report
data. Results based on standardized and validated questionnaires
can be assumed to correctly indicate chronic psychiatric comorbidity. However, questionnaire measures do not represent
diagnoses of specific mental disorders. Only detailed psychological
assessment and structured clinical interviews will clarify whether
patients scoring above a given questionnaire cut off have diagnoses
according to ICD-10 or DSM-IV-R. Even though studies on
sensitivity and specificity of the applied screening tools exist for the
general medical field, they are still missing for the perioperative
setting.

Clinical Implications
There are four major clinical implications of this study. (1) The
finding of stable and chronic psychiatric comorbidity and its
association with interest in psychotherapy suggests an implementation of the assessment of psychological problems and their
treatment in routine care of anesthesiology and surgery. (2) There
is no evidence that elevated preoperative symptoms of psychological distress in surgical patients are only signs of transient worries
that are easily overcome by spontaneous remission. Depression,
anxiety and substance use disorders should be considered as
serious comorbid conditions in these patients that deserve
adequate treatment. (3) Because the wish for psychotherapy seems
to be independent from surgical field and preoperative physical
health, clinicians should be encouraged not to restrict screening for
need of therapy and psychological distress to patients from specific
surgical fields or with specific medical diagnoses. (4) The
chronicity of psychological distress suggests the application of
comprehensive empirically supported psychotherapy. Screening
and successful motivational interventions are the first steps to help
patients to engage and maintain psychotherapy programs that aim
at recovery from depression, anxiety and substance use disorders.

Acknowledgments
The authors wish to thank the team of the preoperative anesthesiological
assessment clinic, Department of Anesthesiology and Intensive Care
Medicine, Campus Charite Mitte and Campus Virchow-Klinikum,
Charite University Medicine Berlin, as well as the BRIA team for the
excellent help with patient care, data collection and analyses. We also
would like to thank Dr. Heidi Linnen for her help with data analyses.

Author Contributions
Conceived and designed the experiments: LFK CDS HK. Analyzed the
data: ML ALS ST FB AL EWG TN HG EB LFK CDS HK. Wrote the
paper: LFK CDS HK. Acquisition of data: ML ALS ST FB AL LFK HK.
Literature searches: ML ALS ST FB AL EWG TN HG EB. Discussed the
results, commented on the paper, contributed to the critical revision of the
manuscript and approved the final version of the manuscript: ML ALS ST
FB AL EWG TN HG EB LFK CDS HK.

References
11. Tsapakis EM, Tsiridis E, Hunter A, Gamie Z, Georgakarakos N, et al. (2009)
Modelling the effect of minor orthopaedic day surgery on patient mood at the
early post-operative period: A prospective population-based cohort study. Eur
Psychiatry 24: 112118.
12. McKhann GM, Borowicz LM, Goldsborough MA, Enger C, Selnes OA (1997)
Depression and cognitive decline after coronary artery bypass grafting. Lancet
Neurol 349: 12821284.
13. Montin L, Leino-Kilpi H, Katajisto J, Lepisto J, Kettunen J, et al. (2007) Anxiety
and health-related quality of life of patients undergoing total hip arthroplasty for
osteoarthritis Chronic Illness 3: 219227.
14. Stroobant N, Vingerhoets G (2008) Depression, anxiety, and neuropsychological
performance in coronary artery bypass graft patients: A follow-up study.
Psychosomatics 49: 326331.
15. Badura-Brzoza K, Zajac P, Brzoza Z, Kasperska-Zajac A, Matysiakiewicz J, et
al. (2009) Psychological and psychiatric factors related to health-related quality
of life after total hip replacement - preliminary report. Eur Psychiatry 24 119
124.
16. De Groot KI, Boeke S, Van den Berge HJ, Duivenvoorden HJ, Bonke B, et al.
(1997) The influence of psychological variables on postoperative anxiety and
physical complaints in patients undergoing lumbar surgery. Pain 69.
17. Hobby JL, Venkatesh R, Motkur P (2005) The effect of psychological
disturbance on symptoms, self-reported disability and surgical outcome in
carpal tunnel syndrome. The Journal of Bone and Joint Surgery 87-B 196200.
18. Pirraglia PA, Peterson JC, Williams-Russo P, Gorkin L, Charlson ME (1999)
Depressive symptomatology in coronary artery bypass graft surgery patients.
International Journal of Geriatric Psychiatry 14 668680.

1. OHara M, Ghoneim M, Hinrichs J, Mehta M, Wright E (1989) Psychological

consequences of surgery. Psychosom Med 51: 356370.
2. Caumo W, Schmidt A, Schneider C, Bergmann J, Iwamato C, et al. (2001) Risk
factors for postoperative anxiety in adults. Anaesthesia 56: 720728.
3. Linnen H, Krampe H, Neumann T, Weiss-Gerlach E, Heinz A, et al. (2011)
Depression and essential health-risk factors in surgical patients in the
preoperative anesthesiological assessment clinic. Eur J Anaesthesiol 28: 733741.
4. Sinikallio S, Aalto T, Airaksinen O, Herno A, Kroger H, et al. (2009) Depressive
burden in the preoperative and early recovery phase predicts poorer surgery
outcome among lumbar spinal stenosis patients: A one-year prospective followup study. Spine 34: 25732578.
5. Smith P, Attix D, Weldon B, Greene N, Smith P, et al. (2009) Executive function
and depression as independent risk factors for postoperative delirium.
Anesthesiology 110: 781787.
6. Vaeroy H, Juell M, Hoivik B (2003) Prevalence of depression among general
hospital surgical inpatients. Nord J Psychiatry 57: 1316.
7. Zhong B, Chen H, Zhang J, Xu H, Zhou C, et al. (2010) Prevalence, correlates
and recognition of depression among inpatients of general hospitals in Wuhan,
China. Gen Hosp Psychiatry 32: 268275.
8. Kip MJ, Neumann T, Jugel C, Kleinwaechter R, Weiss-Gerlach E, et al. (2008)
New strategies to detect alcohol use disorders in the preoperative assessment
clinic of a German university hospital. Anesthesiology 109: 171179.
9. Tnnesen H, Nielsen P, Lauritzen J, Mller A (2009) Smoking and alcohol
intervention before surgery: Evidence for best practice. Br J Anaesth 102: 297
306.
10. Gallagher R, McKinley S (2009) Anxiety, depression and perceived control in
patients having coronary artery bypass grafts. J Adv Nurs 65 23862396.

PLOS ONE | www.plosone.org

December 2012 | Volume 7 | Issue 12 | e51167

Psychological Distress in Surgical Patients

19. Krannich J-H, Weyers P, Lueger S, Herzog M, Bohrer T, et al. (2007) Presence
of depression and anxiety before and after coronary artery bypass graft surgery
and their relationship to age. BMC Psychiatry 7 47.
20. Rymaszewska J, Kiejna A, Hadrys T (2003) Depression and anxiety in coronary
artery bypass grafting patients. Eur Psychiatry 18: 155160.
21. Timberlake N, Klinger L, Smith P, Venn G, Treasure T, et al. (1997) Incidence
and patterns of depression following coronary artery bypass graft surgery.
J Psychosom Res 43 197207.
22. Vingerhoets G (1998) Perioperative Anxiety and Depression in Open-Heart
Surgery. Psychosomatics 39 3037.
23. Lange L, Spies C, Wei-Gerlach E, Neumann T, Salz A-L, et al. (2011) Bridging
Intervention in Anaesthesiology: First results on treatment need, demand and
utilization of an innovative psychotherapy program for surgical patients. Clin
Health Promot 1: 4149.
24. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Loewe B (2009) An ultrabrief screening scale for anxiety and depression: The PHQ4. Psychosomatics
50: 613621.
25. Loewe B, Wahl I, Rose M, Spitzer C, Glaesmer H, et al. (2010) A 4-item
measure for depression and anxiety: Validation and standardization of the
patient health questionnaire (PHQ-4) in the general population. J Affect Disord
122: 8695.
26. Derogatis LR (1993) The Brief Symptom Inventory (BSI): Administration,
scoring and procedures manual (3rd ed.). Minneapolis, MN: National Computer
System.
27. Hautzinger M, Bailer M (1992) Allgemeine Depressions-Skala (ADS) [Center for
Epidemiological Studies Depression Scale (CES-D)]. Gottingen: Beltz Test
Verlag.
28. World Health Organization (1998) Info Package: Mastering Depression in
Primary Care, Version 2.2. Copenhagen: WHO, Regional Office for Europe.

PLOS ONE | www.plosone.org

29. Neumann T, Neuner B, Gentilello LM, Weiss-Gerlach E, Mentz H, et al. (2004)

Gender differences in the performance of a computerized version of the Alcohol
Use Disorders Identification Test in subcritically injured patients who are
admitted to the emergency department. Alcohol Clin Exp Res 28: 16931701.
30. Reinert D, Allen J (2007) The Alcohol Use Disorders Identification Test: An
update of research findings. Alcohol Clin Exp Res 31: 185199.
31. EuroQOL-Group (1990) EuroQOL - a new facility to the measurement of
health-related quality of life. Health Policy 16: 199208.
32. AmericanSocietyofAnesthesiologists (1963) New classification of physical status.
Anesthesiology 24: 111.
33. Wolters U, Wolf T, Stuetzer H, Schroder T (1996) ASA classification and
perioperative variables as predictors of postoperative outcome. Br J Anaesth 77:
217222.
34. Borowicz L, Royall R, Grega M, Selnes O, Lyketsos C, et al. (2002) Depression
and cardiac morbidity 5 years after coronary artery bypass surgery.
Psychosomatics 43: 464471.
35. Bosch J, Engeland C, Cacioppo J, Marucha P (2007) Depressive symptoms
predict mucosal wound healing. Psychosom Med 69: 597605.
36. Kleinwachter R, Kork F, Weiss-Gerlach E, Ramme A, Linnen H, et al. (2010)
Improving detection of illicit drug use in preoperative anaesthesiological
assessment. Minerva Anestesiol 76: 2937.
37. Rosenberger P, Jokl P, Ickovics J (2006) Psychosocial factors and surgical
outcomes: An evidence-based literature review. J Am Acad Orthop Surg 14:
397405.
38. Spies C, Nordmann A, Brummer G, Marks C, Conrad C, et al. (1996) Intensive
care unit stay is prolonged in chronic alcoholic men following tumor resection of
the upper digestive tract. Acta Anaesthesiol Scand 40: 649656.

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